Billing like lawyers


Category : Medical Rants

Regular readers know my position on the financing of outpatient practice. Our current model does not work. We live under reimbursement controls, yet have no expense controls. We receive the same reimbursement for most visits, almost regardless of the necessary time needed for the visit. We have not received any income for other time consuming tasks (directly related to our physician roles). Many physicians are changing that – That’s Going to Cost You: Pinched Between Rising Costs and Lower Revenues, Some Doctors Are Charging Patients for Phone Time, Paperwork and Other Services

While I prefer a modified retainer approach (patients would pay a set fee for a year of medical care), until we adopt such a system, these charges are ethical and necessary, for our only commodity is our time.

“Here’s my philosophy,” said Joseph A. Leming, the practice’s managing partner. “Whenever physicians incur a cost or extend liability, they should be able to capture revenue to offset that cost or liability. The fact is, the cost of doing business is just going nuts.”

Pincered by rising overhead and declining reimbursement — and beset by burgeoning mounds of required paperwork — a small but growing number of medical practices are quietly charging for services they have long provided for free.

Among the new billable items: talking on the telephone with or e-mailing patients or their relatives; providing copies of records to patients or sending files to another doctor; calling a pharmacy with a prescription refill; and completing forms for school, disability, medical leave, life insurance or summer camp. Some practices, including Capitol Medical Group, are charging patients for missed appointments or those canceled without at least 24 hours notice.

“Across the board, doctors are looking at ways to improve their bottom line,” said Regina Regembal, a medical practice consultant in Winchester, Va., who noted that her clients in Virginia and North Carolina are actively considering whether to impose such fees. “The groups I work with don’t want to do these things, but they want to able to pay their bills.”

While the nascent trend is impossible to quantify, officials of medical organizations and practice consultants say the new surcharges are more likely to be found in the trio of primary care specialties that are the least lucrative and most patient-intensive: internal medicine, pediatrics and family practice.

“Over the last 10 years there has been pressure on physician fees,” noted John DuMoulin, director of practice advocacy for the American College of Physicians, a group that represents the nation’s internists. Prompted by members’ inquiries, the College has drafted new guidelines for the reimbursement of telephone and e-mail communications.

The costs of running a medical practice have risen about 60 percent during the past decade, DuMoulin estimates, while reimbursements by the federal government and private insurers have remained static. “Patients are coming into doctors’ offices less and demanding more services when they get there,” he added. And primary care physicians complain that they routinely spend about two hours per day doing paperwork or returning phone calls — services for which they are rarely reimbursed.

But then regular readers know about these factors. I keep saying that we must change our reimbursement system. I will keep saying this, as it does represent a major impediment to providing outpatient care for our population.

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Comments (2)

I certainly prefer your prescription (however tentative) to billing per phone call or EMail: I have visions of lawyer-like billings of seventy hours per day…

You wrote:

While I prefer a modified retainer approach (patients would pay a set fee for a year of medical care)

Is that how capitation works? The HMO pays a fixed fee for each patient treated by the doctor? A couple of years ago that form of reimbursment was getting some attention and I thought both the doctors and patients hated it. And it it’s easy to understand why. It’s a nice deal for the HMO because it transfers the risk to the doctor and gives the HMO a guaranteed profit. And it puts the doctor in the ethical bind that each additional treatment for the patient comes out of the doctor’s income creating an incentive to treat patients as cheaply as possible.